Communicating with People with Mental Illness: The Public's Guide

John arrived in Washington this morning after a fifteen-hour bus trip. He spent his last twenty dollars for the bus ticket and he ponders how to get more cigarettes as he slowly walks toward the Capitol. Looming on the horizon, it appears like something from another time or planet and it beckons John toward it as the voices in his head grow louder. Families touring the city hardly notice his tattered clothing or the fearful look in his eyes. The ones who do notice, walk carefully out of their way to avoid him.

As he drifts up Pennsylvania Avenue, he sees the white sparkling mansion, home of the President, and he wonders if the most powerful man on earth can stop his pain and suffering. He shuffles toward the gate but the fences, concrete blocks, and uniformed Secret Service officers dissuade John from further approach. He continues his quest down the avenue. He pauses to look at the man made of bronze standing on the pedestal gazing out on the water like a figurehead on the bow of the great domed mother ship. He pulls himself together and walks into the office of his senator.

"I have to see the Senator!" he demands. "Do you have an appointment?" replies the staff member. "No, but he's expecting me," says John confidently, as he continues to explain his quest. "He's got to stop them!" "Who?" asks the staff member. "The NSA, or the CIA, I'm not sure who they are. They're using Echelon and V2K to control my mind... brainwashing me, causing cyberworms in my brain and ruining my life!"

This scene is not unusual in government agencies in the nation's capital and in other public agencies around the country. At least ten percent of our population will require treatment for some form of mental illness in their lives. We all know people who have experienced some form of mental disorder or perhaps you have yourself.

Communicating with People Who Are Mentally Ill

In our society there is a powerful negative stigma attached to mental illness, especially the more severe forms, like schizophrenia. Schizophrenia is a type of psychosis that is generally characterized by hallucinations, disordered thinking and delusions. Schizophrenia is what John suffers from. Most schizophrenics and others who are mentally ill are no more likely to be dangerous than the general population but because of their bizarre and unpredictable behavior they often frighten people. Of course, some mentally ill people are dangerous. That will be addressed later.

Popular media fuel stereotypes about mental illness and dangerousness, because that is how they generally are portrayed on the screen. Newspapers sensationalize crimes committed by people with mental illness. Our fear of mentally ill people also stems from our own inability to communicate with them and our lack of knowledge about mental illness. Just because they may be behaving in ways that don't make sense to us, doesn't mean that we can't provide them with service that is part of our jobs to provide any constituent or customer.

Guidelines for Communicating with a Person with Mental Illness

Be respectful to the person. When someone feels respected and heard, they are more likely to return respect and consider what you have to say.

If they are experiencing events like hallucinations, be aware that the hallucinations or the delusions they experience are their reality. You will not be able to talk them out of their reality. They experience the hallucinations or delusional thoughts as real and are motivated by them. Communicate that you understand that they experience those events. Do not pretend that your experience them.

Some people with paranoia may be frightened, so be aware that they may need more body space than you.

Do not assume that they are not smart and will believe anything you tell them.

Mental illness has nothing to do with the person's intelligence level. Do not lie to them, as it will usually break any rapport you might want to establish.

Do not just pass them on to another person like a "hot potato" just to get rid of them. This may save you time in the short run, but may come back to haunt you later, or cause problems for someone else. Anyone who is passed unnecessarily from one person to another can become angry or violent. Refer them to someone else only if it is an appropriate referral.

Listen to the person and try to understand what he/she is communicating. Often, if you do not turn off your communicating skills, you will be able to understand. Find out what reality based needs you can meet.

If needed, set limits with the person as you would others. For example, "I only have five minutes to talk to you" or "If you scream, I will not be able to talk to you."

Keep a current list of community resources, like shelters, food programs, and mental health services that you can suggest to them (if they need it). Some people will not accept the suggestion, but some will.

Call for help (police, security, or colleagues) if you feel physically threatened or need help de-escalating the person.

Mental Illness and Violence

Mental illness alone does not increase the risk of violence, but when mental illness is combined with other risk factors such as substance abuse, it does increase the risk of violence. Previous research has produced mixed results about the link between mental illness and violence.

In a 2009 landmark study conducted by Eric Elbogen and Sally Johnson at UNC-CH School of Medicine, data were evaluated on nearly 35,000 people, all interviewed about their mental health, history of violence, and use of substances between 2001 and 2003. They found that the percentage of participants reporting a mental illness reflected the percentages found in the general population and in other studies.

In a second interview conducted in 2004 or 2005, participants were asked about any violent behavior, such as committing a sexual assault, fighting, or setting fires, in the time between interviews. in the time between the first and second interviews, 2.9% of participants said they had been violent. When Elbogen and Johnson evaluated the possible associations between mental illness, violence, and other factors, having a mental illness alone did not predict violence, but having a mental illness and a substance abuse problem did increase the risk of violence.

When Elbogen and Johnson looked at those who only had a severe mental illness, 2.4% had been violent. But when they looked at those with major depression and substance abuse or dependence,

6.47% had been violent. When they looked at those with schizophrenia, 5.15% reported violent behavior in the time period between the interviews. But when a person with schizophrenia also had substance abuse or dependence problems, 12.66% reported violent behavior in the time between the interviews. The highest risk for violence was found in those who had mental illness, a substance abuse problem, and a history of violence. These participants had 10 times the risk of violence than those who only had mental illness.

Another excellent overview of mental illness and violence was conducted by by Marie E. Rueve, MD; and Randon S. Welton, MD, Lt Col, USAF in 2008.

Whether a person is mentally ill or not, one does not just "snap" as is often reported in the media. There is generally a progression of behaviors down a pathway toward violence and those behaviors often become noticeable as a person moves down that path. As public service providers, parents, teachers, friends, family, co-workers, and law enforcers, we should learn how to recognize those behavioral warning signs and communicate our concerns to people who might be able to help. Unfortunately, it can be extremely difficult to get help for someone with mental illness that doesn't accept the help.

Remember that not just the homeless and the poor suffer from mental illness. Mental illness has no racial, economic or intellectual boundaries. You may not be in the business of being a social worker or psychologist. You may be too busy at work to spend a lot of time with any one person, mentally ill or not. Many people who you may consider "strange" have a right to seek your services and have a real need that you can meet within your job description. Try to limit your interventions to relatively short periods of time, but realize that taking time to try to communicate effectively with the person may save you a lot of time in the long run and help someone in the process.

I think this article is very helpful towards identifying fear and stigma as natural barriers to communicating with people who have severe symptoms such as psychosis. However, I would like to note that the use of "schizophrenics" supports the stigma my labeling the group of people.